Nursing Care Essay: Assessment, Goal Setting and Care Planning

Running head: NURSING CARE ESSAY
Nursing care essay
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NURSING CARE ESSAY
Introduction:
Nursing care is one of the most vital aspects associated with health care delivery and
disease management for the patients. It has to be mentioned in this context that the nurses are
the first point of contact for the patients with their health care delivery scenario. For instance,
the patients along with their family members have been reported to share most of their
concerns and grievances with the nurses due to the therapeutic and mutually respectful
relation that the nurses have with the patients (Ersser 2018).
Similarly, nurses are also the facilitator of the care delivery in the health acre scenario
as well, for instance, whereas the physicians and other health care professionals in the
multidisciplinary team is associated with just diagnosis and treatment, although the care
planning, intervention administration and evaluation of the progress due to the interventions
is carried out by the nurses. The most important element of the nursing care is assessment,
goal setting and care plan development in accordance of the goals set. This assignment will
focus on the nursing assessment, goal setting and care planning along with implementation,
taking the assistance of the case study of Christopher Collins.
Background of the patient:
In the process of nursing assessment and care delivery, understanding the patient and
the key complaints or care needs of the patients is extremely crucial. Hence, exploring and
analysing the background information of the patient is extremely integral in accurate
assessment and care delivery. In this case, the background will discuss the baseline data of
the patient, the past medical history, present complaints and vital signs recorded. The patient
chosen in this case is named Christopher Collins, a 54 year old man who had been previously
diagnosed with early stage osteoarthritis in the left knee of the patient and altering the
mobility to a large extent. He had been admitted to the facility for left high tibia knee
osteotomy, and as he had an uneventful post-operative procedure, he had been discharged

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NURSING CARE ESSAY
two days after the surgery was successfully completed. During the discharge, non-steroidal
anti-inflammatory medication for pain relief, non-weight bearing on crutches and fitted for a
supportive knee brace until his planned outpatient review in two weeks’ time. The presenting
claims of the patient include complaints of pain at the incision site, along with nausea and
feeling of shaking or shivering. His wound had appeared sutured, tight, shiny and red, and
along with that there had been several small areas were dehiscence is evident with pus
present, indicating the signs of surgical site infection. His past medical history includes
asthma since childhood along with being diagnosed with osteoarthritis in the past. His vitals
assessment indicates high respiratory rate at 27 bpm, low oxygen saturation at 94% on 60%
oxygen including verbal reports of feeling increasingly breathless, having cool peripheries
and high body temperature, and lastly a pain score of 5 out of 10. Hence, based on the
presenting complaints of the patient, he is indicating all signs of surgical site infection in
incision site.
Assessment data:
Objective and subjective data of Mr. Collins give an idea about potential problems
found in patient. The review of airway and breathing related data of patient suggest that Mr.
Collin’s airway is clear, however he has breathing related problem. His RR is 27 which is
little above the normal range (normal respiratory rate is 12 to 20 breaths per minute). The
subjective report of the patient also suggests that breathlessness is one problem for patient.
The circulatory system assessment data showed heart rate (HR) of 125, BP 98/57 and cool
peripheries. The HR is found above the normal range as normal range is 60-100 beats per
minutes. Hence, high HR is indicative of risk of tachycardia in patient. His blood pressure is
also below the normal range and Mr. Collins is found to be hypotensive.
Mr. Collins had undergone a left high tibia knee osteotomy and his current complain
is pain at the incision site and nausea. To assess his consciousness, Glasgow coma scale

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NURSING CARE ESSAY
(GCS) score was recorded. The GCS score of 15 is the best score indicating that the patient
has bet eye, verbal and motor response. Furthermore, as pain at the incision site is a major
issue of Mr. Collins, pain score assessment has been done to find the severity of pain. The
pain level is 5/10 indicating moderate pain. Exposure to skin was also done to find out
changes in characteristics and nature of skin. This has been done to detect signs of
nosocomial infection in patient. Motie, Ansari and Nasrollahi (2014) suggest that surgical site
infection is the common cause of nosocomial infection and as it may be caused due to
multifactorial condition, assessment of the surgical site is necessary. The assessment of the
surgical site of the left knee revealed suture at the left knee. The skin near the surgical site
was found to be tight, shiny and red indicative of inflammation. The skin near the surgical
site was warm to touch. Skin dehiscence with pus is indicative of surgical site infection and
delay in wound healing for Mr. Christopher Collins.
Apart from A-E assessment, fluids and glucose assessment has been done to detect if
the patient is under any fluids or not. Currently, IV cannula has been inserted and he is
receiving Glucose 5.1. Other investigative result like FBC and ABG reading suggest that
platelet count for patient is very low and he may be at risk of bleeding. In addition, review of
ABG asssement revealed pH 7.3, PaCO2 21, PaO2 80, HCO3 18, BE – 4.0. Out of these four
parameters, HCO3 values, PaCo2 value and PaO2 value is found to be abnormal thus
suggesting risk of respiratory failure. ABG interpretation is vital for Mr. Collins to detect
signs of respiratory alkalosis or over ventilation (Ranson and Pierre, 2016).
Identified health problems: 250
Based on the review of assessment data for Mr. Collins, two potential problems has
been identified for patient. Firstly, the patient is found to suffer from surgical site infection
due to changes in skin integrity near the wound areas. The surgical site infection of the left